placebo for coughs in kids, and an adult perspective

an interesting article found that placebo was more effective than no treatment in kids with cough (see placebo for cough in kids JAMA peds 2014​ in dropbox, or doi:10.1001/jamapediatrics.2014.1609). this was a 13 month study in 2 outpatient pediatric practices of kids aged 2-47 months who had nonspecific acute cough of less than 7 days. parents were given surveys the day before and after the allotted treatment, which was either pasteurized agave nectar, caramel-colored placebo (each given 30 minutes prior to bedtime), or "no treatment". all parents were instructed in routine care of the child: hydration, saline nasal spray, and use of acetaminophen/ibuprofen as needed (ie, the "no treatment" group did get treatment, just not a teaspoon of "meds"). the survey assessed cough frequency, cough severity, congestion severity, rhinorrhea severity and the cough effect on child and parent sleep. results:​

--119 children completed the study, mean age 23 months, 50% female, 87% white non-Hispanic.
--no difference in any of these outcomes between administering agave nectar or placebo (though agave nectar was nonsignificantly better on all outcomes)
--significant differences between either one of these two treatments and "no treatment" for all of the above outcomes, all with p<0.05
--subgroup analysis suggested that the effects of agave nectar over placebo were somewhat more pronounced in those under 1 year old, though nonsignificant (but only 30 kids <1yo)

so, background is that acute cough is a remarkably common outpatient complaint in kids and a common reason for a healthcare visit, with nocturnal cough disturbing sleep in 88% of children and 72% of parents. given current valid concerns about adverse events with medications as well as their unclear efficacy in young children (eg antihistamines, decongestants, antitussives), providers have limited medication options. there are some studies showing efficacy of honey, but that should not be used in kids <1yo for concerns about botulism. in above study, they chose agave nectar, since it sort of tastes like honey (though no data that it really works), does have some anti-inflammatory properties (as does honey), but lacks honey's anti-oxidant effects.​

so, this article does suggest that placebo has a role for cough in kids (there was an analysis in 2002 suggesting that 85% of the treatment response in adults with cough was attributable to placebo effect). this is really not so surprising. there is an obvious interconnection between an individual's clinical condition and their psychosocial state. to me, perhaps the most obvious example is the therapeutic effect of the provider-patient relationship itself. many patients derive tremendous benefit without specific treatment. there are a slew of articles on the placebo effect, showing both the dramatic efficacy of placebo, the relatively frequent adverse effects as well, and effect even studies where the patients benefited even if aware that they were taking a placebo. there was an interesting article i ran across last year on this -- see http://harvardmagazine.com/2013/01/the-placebo-phenomenon​  but, one of my favorite articles in the medical literature was an analysis of the CHARM trial, a placebo controlled trial of candasartan in patients with congestive heart failure (see chf CHARM trial adherence lancet 2005 in dropbox, or Lancet 2005; 366: 2005–11), which found that those patients who adhered well to their treatment did well and had a lower all-cause mortality, and it didn't matter whether they were assigned to candasartan or to placebo -- ie, people who took their assigned medicine (who were probably more open to having a good effect from that medicine and perhaps more open to "taking care of themselves") had similarly lower mortality independent of whether their assignment was to "active" medication or not.....